Japan spends only 8% of its GDP on healthcare, ranking it 20th in OECD countries, largely due to its strict and universal rules on fees for services. This cost-containment in a universal coverage scheme has occurred despite many factors that are typically associated with high costs—namely a private sector dominated, fee-for-service system, and a lack of gatekeeping by family doctors. The third paper in The Lancet Japan Series analyses this success and questions its sustainability, as well as suggesting lessons other countries may learn. This third paper is by Professor Hideki Hashimoto, School of Public Health, University of Tokyo, Japan, Professor Naoki Ikegami, Department of Health Policy and Management, Keio University, Japan, and their colleagues.
Japan's low healthcare spending as a proportion of GDP is on a par with the UK (8%), but half that of the USA (16%) and lower than France and Germany (11%), despite having a much higher proportion of citizens aged over 65 years than any OECD country. Furthermore, Japanese people see a doctor on average 13 times per year, compared with 5 times in the UK and 4 times in the USA. Japan has lower numbers of doctors and nurses per hospital bed than all OECD countries. Japan also has lower use of, for example, surgery under general anaesthetic (half the rate of the USA). The authors say that subspecialty accreditation remains underdeveloped, and general practice is yet to be recognised as a speciality in the country. Yet despite these differences and challenges, Japan has similar health outcomes in acute inpatient care, such as post-surgical mortality and cancer survival, to other comparable OECD nations.
The main reason for successful cost containment is the tight control using a nationally uniform fee schedule (where physicians all over the country receive the same rebate for a specific service). The government has also been able to reduce these fees in tough economic times. However, several factors mean this model is no longer tenable: for example, introduction of a new fee model in 2003 with the introduction of the Diagnosis Procedure Combination for most inpatient procedures, which includes a fee-for-service and a per-diem inclusive rate. The rising expectations of patients are mismatched with supply of quality service under the model. And there is a need to improve the quality of primary care by investing in the education and training of physicians.
The authors say that the tight control of the current fee payment schedule should be restructured to allow increased flexibility on the payment side. For example an inclusive payment system, requiring less detail for getting reimbursed and giving more flexibility to providers, while tightening control on how services are organised and delivered. Regional governments (prefectures) should take more control of service delivery: something that would be facilitated by consolidating all health insurance plans within prefectures, as recommended in paper 2. This would put the prefectures under pressure to make healthcare more efficient. Finally, Japan's system of medical education needs to be reformed to improve quality of care. The authors conclude: "Structure and process issues in quality of care could not be addressed by the cost-containment policy, suggesting that the priority should initially be placed on expansion of access and prevention of impoverishment from health care, after which the efficiency and quality of services should then be pursued."
Professor Hideki Hashimoto, School of Public Health, University of Tokyo, Japan. T) +81-3-5841-1887 E) hidehashimoto-circ@umin.ac.jp
Journal
The Lancet